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Aaron Carroll will heave a great sigh when he sees me write about this, but the Center for Studying Health System Change—the group behind the Medicaid physician access data I highlighted on Monday—has just put out a new study on the topic. Peter Cunningham, author of the study, captures the gist of it in this sentence: “Growth in Medicaid enrollment [especially in the South and Mountain West] will greatly outpace growth in the number of primary care physicians willing to treat new Medicaid patients.”

The reason why the South and Mountain West will be disproportionately affected is because those states currently have relatively smaller Medicaid programs that will be more dramatically expanded by PPACA, combined with a lower ratio of primary care physicians per capita. “Things are not going to be pretty in those states,” said Alwyn Cassil of CSHSC in an interview with Kaiser Health News.

In response to my concerns about how Medicaid’s absurdly low reimbursement rates have led physicians to stop participating in the program, some have pointed out that PPACA raises Medicaid reimbursement rates to (declining) Medicare rates in 2013 and 2014. However, in order to maintain the fiction that PPACA is “deficit neutral,” the law reverts back to Medicaid’s older, lower rates in 2015. Cunningham points out that, as a result, the temporary rate increase is likely to have no effect on physician access:

A limitation of this analysis is that the simulated rate increases assumed a permanent increase in Medicaid reimbursement relative to Medicare, while the rate increases specified in the law are limited to 2013 and 2014. The temporary nature of the rate increase may limit the incentive for more physicians to accept Medicaid patients, in which case the increase in Medicaid PCP supply will be less than shown in this analysis. While the federal government and/or states have the option of extending these increases beyond 2014, budgetary pressures and uncertainty about what shortages will develop when reform is implemented are likely to preclude decisions on extensions.

“If you thought the [temporarily] increased Medicaid reimbursement was going to get a lot more doctors to jump in and be willing to take on new Medicaid patients, it’s not going to work that way,” notes Cassil.

Furthermore, it’s important to remember that Medicaid’s problems are not limited to access to primary care. Indeed, a major reason why Medicaid beneficiaries fared so poorly in the UVa surgical outcomes study is that Medicaid patients have poor access to specialists—especially the high-volume surgical specialists who are proven to deliver superior clinical outcomes when compared to generalists.

My critics say that I'm “cynical” because I say that Medicaid’s reimbursement rates are too low, and yet oppose spending more money that we don’t have. This is a false dichotomy. There are a lot of things we can do to make Medicaid more cost-efficient: starting with converting the program into block grants for the states, and letting states focus on fully funding care for the truly needy.